During a 2006 biopsy of a worrisome growth on his thyroid gland, while a needle was still lodged in his neck, Arizona veterinarian Brett Cordes was surprised by a question from his endocrinologist.

The doctor, Cordes said, “asked me if I handled chemotherapy and hazardous drugs” at work, and he acknowledged that he did. For Cordes, who eventually was found to have a rare thyroid affliction called Hurthle cell cancer, the exchange with the physician was life-changing. Cordes vowed that, from then on, he would protect himself from the risky exposures that veterinarians and their assistants can encounter on the job, and would urge colleagues to do the same. Cordes remembered thinking to himself at the time, “I’m not as invincible as I thought I was, and I’m too cavalier. What have I been doing all this time?”

Fortunately Cordes, at age 47, says he now is considered cancer free. It’s impossible to know for sure what caused his disease. But Cordes, who began working in a veterinary clinic doing cleanup while in his teens, is convinced it was his longtime on-the-job exposure to chemotherapies and other hazardous drugs used to treat pets. It spurred him to become an advocate in a successful push for tougher safety standards, due to take effect in December 2019, for handling hazardous drugs in veterinary medicine and throughout health care.

Working as a veterinarian or as an assistant in a veterinary clinic never has been for the faint-hearted. While bites and scratches are the most common injuries, other hazards abound. They include accidental needlestick punctures, afflictions known as zoonotic diseases that can pass from animals to humans, back injuries from lifting and holding animals, along with exposure to anesthetic gases and radiation. In fact, veterinary staffers sometimes still are known to hold an animal while it is being X-rayed — a vast difference from human medicine, where nurses head into a separate room.

In a 2016 federal survey, veterinary services posted the second-highest rate of nonfatal job-related injuries and illnesses among all of the U.S. industries tracked, worse than local police and fire protection or any manufacturing field, and behind only state-owned nursing and residential care facilities, which include homes for people with mental health or substance abuse problems.

What’s more, studies have found that veterinarians for years have had high suicide rates, and the profession increasingly has focused on that problem.

But cancer treatment for pets has boomed in recent decades, reflecting a surge in spending on veterinary care as Americans increasingly have doted on their dogs and cats. According to the market research firm Packaged Facts, spending on veterinary services and treatments in the U.S. reached $26.87 billion last year, up 152 percent since 2001, even as consumer prices overall climbed by only about 40 percent.

The growing amount of chemotherapy has stirred up a safety threat: increased exposure to drugs that not only treat cancer but can also cause the disease, as well as other afflictions. Experts say scant research has been conducted on the impact of on-the- job exposure to chemotherapy drugs in veterinary medicine, and many caution against overreacting to the risk. “We want to be careful, but we don’t want to be paranoid,” said Dr. Annette N. Smith, an Auburn University professor who was the lead author of a “consensus statement” published this year that focused on ways to minimize harm to veterinary workers and pet owners exposed to chemotherapy drugs.

Still, there have been worrisome research findings in human medicine. That’s particularly true for women, who dominate the veterinary work force. Studies have identified heightened risks of infertility, spontaneous abortions, chromosome abnormalities and possibly leukemia and other cancers among nurses and other health care workers who handle chemotherapy drugs in human medical care. “The only known safe level of chemotherapy exposure is no exposure,” cautioned Dr. Daina Budreckis, a veterinary oncologist – a cancer specialist – in Ventura, California.

Although chemotherapy doses tend to be much lower in veterinary medicine, safety practices in veterinary settings often fall short of the norm in human health care. As a 2014 study put it, “The complex field of chemotherapy safety has not been fully embraced by veterinary medical practice.” The paper said “human outpatient cancer clinics are staffed with medical oncologists and trained oncology nurses” while in veterinary medicine, “chemotherapy in local practices is literally placed in the hands of general practitioners, staff, and pet owners, without any oversight to evaluate the safety of administration.”

A University of Illinois veterinary team demonstrates an ultrasound scan that can be performed to look for tumors. (Photo by L. Brian Stauffer, University of Illinois News Bureau)

The risks are widely thought to be greatest at rural or small-town veterinary clinics that don’t routinely provide chemotherapy. They typically serve pet owners who live too far from, or can’t afford, veterinary hospitals with cancer specialists.

Small-town veterinarians “have to do everything,” including chemotherapy treatment that “they’re not trained to do,” said Dr. Lisa Parshley, a veterinary oncologist and former president of the Washington State Veterinary Medical Association.

Parshley, who has worked with officials on implementing a pioneering Washington law approved in 2011 regulating the handling of hazardous drugs, including chemotherapy agents, has observed veterinary clinics around the state. When it comes to drug handling at independent general veterinary practices, some are doing “a really good job,” Parshley said. “And then I think there are some that are appalling. I won’t lie.”

Dr. Kim A. Selting, president of the Columbia, Missouri-based Veterinary Cancer Society and an associate professor at the University of Illinois, agreed that “there are certainly people who are using chemotherapy and being nonchalant about it, being just too cavalier with chemotherapy safety.” That happens, Selting said, even though there are readily available devices and techniques to effectively prevent exposures.

“A lot of people do chemotherapy because it has very little overhead … Anyone can do chemotherapy if you order the drug and put the catheter in. Then you just calculate the dose and give the drug,” said Selting. She added that “the bigger art of chemotherapy is knowing why you’re doing what you’re doing, when to do what you’re doing, when to change your plans or quit or whatever.”

Selting, whose organization has 850 members in the U.S., said many general practitioners “do a fine job with chemotherapy,” and that she couldn’t estimate how many don’t take adequate precautions because “they don’t self-report. It’s not like they would contact the AVMA [American Veterinary Medical Association] and say, ‘Hey, just so you know, I’m not doing it right.'”

Dr. Kim A. Selting, president of the Veterinary Cancer Society, said some veterinarians are “too cavalier with chemotherapy safety.” (Photo by L. Brian Stauffer, University of Illinois News Bureau)

Advanced expertise in providing chemotherapy to animals is in short supply. Veterinary oncologists – who typically go through four or five years of additional training after becoming veterinarians — remain a rare breed. There are somewhat over 110,000 veterinarians in the U.S., but fewer than 600 are board-certified oncology specialists, according to American Veterinary Medical Association figures.

Yet even veterinary teaching hospitals — which along with big-city specialty hospitals are generally thought to do the best job in handling chemotherapy safely — may sometimes slip up. At Michigan State University’s veterinary teaching hospital, federal evaluators in 2010 found substantial lapses. For example, the air in a chemotherapy drug preparation area was re-circulated in the room, instead of being exhausted outdoors, away from workers. Sometimes, the federal review said, employees also failed to wear protective disposable gowns and double gloves.

While the review said three employees “reported headache, nausea, and abnormal menstruation,” it added, “We were unable to determine if the health effects reported by employees were work related. However, similar effects have been reported with occupational exposure to chemotherapy drugs in other studies.”

When it comes to drug handling at independent general veterinary practices, some are doing “a really good job. And then I think there are some that are appalling. I won’t lie.”

–Dr. Lisa Parshley, former president of the Washington State Veterinary Medical Association.

BluePearl is appealing all of the citations. BluePearl and Mars officials declined to be interviewed for this story but, in an email, company officials said they “disagree with many of the factual findings” by Washington State Division of Occupational Safety and Health inspectors and “look forward to working with DOSH to resolve the allegations on appeal.”

Jenny Fisher, who as director of education for a veterinary medical products company, Practivet, provides advice to clients on ways to handle hazardous drugs, said she has witnessed “very scary” situations at veterinary practices.

Jenny Fisher, a veterinary safety educator, said she has seen cancer medications being prepared in employee break rooms where pregnant women could be exposed.

She said she has seen, among other things, staffers preparing cancer medications in areas without a chemotherapy hood – an apparatus that, like other types of biological safety cabinets, sucks in and then vents hazardous vapors, particles and other substances to protect workers. In fact, Fisher has observed chemotherapies being prepared in employee break rooms where pregnant women could be exposed.

Fisher, who lives in Baton Rouge, Louisiana, advises clinic owners around the country to improve their procedures, but some resist because of the cost or because they don’t know or accept that chemotherapy exposure is a serious risk. “When I hit those roadblocks, it’s frustrating,” she said. On one occasion within the last two years, Fisher said, a clinic owner asked her to leave while she was in the middle of a PowerPoint presentation on workplace safety. As Fisher recalls the incident, the clinic owner said that “he didn’t want me scaring the staff, because that would not benefit anyone.”

Fisher said health risks exist not only for veterinarians and their assistants, but also for “the people on the shipping dock that are unpacking the boxes that potentially could open and have exposure, if there’s been a busted bottle or something like that. It’s the front desk worker who is intaking the [pet] who is on oral chemotherapy who urinates in the front lobby. It impacts everybody in the hospital.”

Budreckis, the Ventura, California, veterinary oncologist and president of her regional veterinary medical association, attributed some inattentiveness to worker safety to a “very laid-back” attitude common in the field. Budreckis said she has had referrals, in some cases, from general practice veterinarians “who have been giving chemo and it does scare me a little bit.” She said she doesn’t think that these general practice veterinarians “are being conniving in giving them [animals] chemo, but I worry about whether or not they understand the risks to themselves, and to their staff and to, potentially, the pet owners.” Budreckis said she spends an hour with owners of pets getting started on cancer treatment, and includes instruction on dealing with potential chemotherapy spills at home and the traces of dangerous chemicals excreted in the animals’ urine and feces.

Technician preparing a treatment under a chemotherapy hood. (Photo by Stuart Silverstein)

Another key issue, safety advocates say, is the inconsistent training and supervision of clinic staffers who are the workhorses of veterinary practices. There are two-year college programs for veterinary technicians, and four-year programs for veterinary technologists, but much of the work force, for better or for worse, is trained on the job.

State credentialing programs – such as programs to become a registered veterinary technician – include some occupational safety training. However, “there are veterinarians out there who are using people who are untrained and don’t know any better and can end up exposing themselves” to chemotherapies, X-ray radiation or other hazards, said Liz Hughston, a registered veterinary technician in San Jose, California, and president of the fledgling National Veterinary Professionals Union.

Hughston’s organization and the International Longshore and Warehouse Union since April have won votes to represent veterinary clinic staffers at Mars-owned hospitals in San Francisco, Seattle and suburban Portland, although the Oregon election is being appealed by the employer. Union organizers say understaffing – which they maintain can lead to safety problems – has been among the workers’ key concerns.

The notion that workers sometimes are thrown into situations where they aren’t aware of the hazards rings true for Jennifer, a veterinary staffer in Georgia. Jennifer, who asked that her last name not be used to avoid antagonizing a previous employer, got started in the business more than 20 years ago the way many do: She worked in the kennel of a veterinary clinic, handling chores such as cleaning cages, mopping floors and feeding and bathing animals. She eventually passed a credentialing exam and earned the title of registered veterinary technician. Her duties expanded and, under a veterinarian’s supervision, she calculated doses and administered chemotherapy drugs, took X-rays and assisted on surgeries.

At the practice where she got started and worked for more than 10 years, Jennifer said, employees didn’t wear radiation badges to alert them if they absorbed excessive exposure from X-rays. Neither did they put on safety glasses or thyroid shields to guard against the radiation.

“A lot of this I didn’t know was a problem until I left,” she said. “That was the first clinic I worked for, this is where I got my training, and that was the way we did business. That’s the way I thought everybody did it.”

Occupational safety simply wasn’t part of the training. “It was ‘here’s how you take an X-ray,’ not ‘this is what you need to be worried about when taking X-rays,”’ Jennifer said.

But after she was diagnosed with breast cancer in 2015 – and with the same strain of breast cancer that one of her co-workers from that clinic also developed – Jennifer took it upon herself to learn more about workplace safety.

“I don’t think I ever thought that anything I was doing was risky at the time because we just didn’t have the training on it. Nobody said, ‘Hey, you shouldn’t be doing that,’’’ Jennifer said. Her current employer makes job safety a higher priority and doesn’t do chemotherapy treatment, but Jennifer continues to hear from colleagues still exposed to the types of hazards that she once experienced. “I know that there are other people out there that are in the same situations,” she said.

Pressure to upgrade safety practices is intensifying because of a new package of standards for the handling of hazardous drugs due to take effect in December 2019. Those rules — developed by a standards-setting organization, the United States Pharmacopeial Convention, and known as USP 800 — are intended to protect the environment and patients, along with health care workers in all medical fields. USP 800 covers every step from the arrival of the drugs at the loading dock through the administration of the medicines and their disposal.

The new standards are a welcome development for Kim Albin, a veterinary technician who lives near Lansing, Michigan. Albin, a former oncology staffer at Michigan State, says she was one of the employees who reported personal health problems to the federal officials who investigated the work site in 2010.

USP 800, she said, already is spurring some veterinary operations to improve their safety practices. “Things have come leaps and bounds in the last five years,” Albin said.

The USP 800 standards won’t carry their full weight until they are adopted by state regulators. However, they immediately will be recognized under federal law and will establish the “prevailing standard of care,” which could make practitioners who don’t comply with USP 800 vulnerable to lawsuits, according to Lou Diorio, a New Jersey medication safety consultant.

Veterinarians, Diorio said, are “going to have to change how they administer chemotherapy, and obviously they’re going to have to be garbed in a different way. “ His own veterinarian, Diorio added, currently “never wears anything more than safety glasses and rubber gloves.” But under USP 800, when a veterinarian or an assistant administers hazardous drugs, “They’re going to need a head cover, they’re going to need eye protection, they’re going to need a very specific type of a mask — an N95 respirator, they’re going to need double gloves, shoe covers and a chemo gown,” Diorio said.

The new standards also crack down on practitioners who prepare hazardous drugs in a “big, open room,” Diorio said. “There’s going to have to be some sort of engineering control, some sort of containment hood.” He said the cost of adding containment rooms is likely to be veterinarians’ main objection to USP 800.

Many experts, while optimistic that USP 800 will make working conditions safer, say it may prove burdensome for some veterinary practices and prod some to stop providing cancer treatment, reducing the options for pet owners.

Cordes, for his part, left veterinary practice for nearly a decade after developing cancer. “I was afraid of veterinary clinics after a while, the chemical smells, the radiology, the breathing of fumes, the anesthetics, the chemotherapy, all the drugs, all the different hazards.”

Cordes returned to practicing veterinary medicine in 2015, opening a clinic in Scottsdale, Arizona. He says he built the clinic with the aim of protecting the staff as much as possible from safety risks, including ergonomic problems and exposure to anesthetic vapors.

But when it comes to dealing with chemotherapy drugs, Cordes is finished. If his clients want chemotherapy for their pets, Cordes first brings up the pros and cons. If the clients then want to go ahead, Cordes refers them to a veterinary oncologist, in the hope that these specialists will be more likely to take strict safety precautions than veterinarians with general practices.

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